Adjunctive intra-arterial thrombolysis after successful mechanical thrombectomy for acute ischemic stroke: an updated systematic review and meta-analysis of randomized controlled trials

Background and objectives. Mechanical thrombectomy (MT) is the standard of care for acute ischemic stroke with large-vessel occlusion. However, successful macrovascular reperfusion does not always result in optimal functional recovery, partly because of persistent microvascular dysfunction. This systematic review and meta-analysis evaluated the efficacy and safety of adjunctive intra-arterial thrombolysis (IAT) following successful endovascular reperfusion in patients with acute ischemic stroke, compared with MT alone. Materials and methods. Randomized controlled trials (RCTs) comparing adjunctive IAT with MT alone were systematically identified from seven electronic sources. The primary outcome was an excellent functional outcome, defined as a modified Rankin Scale (mRS) score of 0–1 at 90 days. Secondary outcomes included functional independence (mRS 0–2), symptomatic intracranial hemorrhage (sICH), any intracranial hemorrhage (ICH), 90-day mortality, and serious adverse events (SAEs). Pooled effects were expressed as risk ratios (RRs) with 95% confidence intervals (CIs). The protocol was registered in PROSPERO (CRD420261437828). Results. Nine RCTs involving 2,759 patients were included. Adjunctive IAT significantly increased the likelihood of an excellent functional outcome (mRS 0–1) compared with MT alone (RR 1.23; 95% CI 1.13–1.35; p < 0.00001; I2 = 17%) but did not significantly improve functional independence (mRS 0–2) (RR 1.03; 95% CI 0.95–1.11; p = 0.48). No statistically significant differences were observed in sICH, 90-day mortality, or SAEs. However, adjunctive IAT was associated with an increased risk of any ICH (RR 1.17; 95% CI 1.03–1.33; p = 0.02). Conclusions. Adjunctive IAT following successful MT may improve the likelihood of an excellent functional outcome but does not significantly improve functional independence. The increased risk of any ICH should be considered when balancing potential functional benefits against hemorrhagic risk.